Sao Paulo Medical Journalhttps://www.scielo.br/feed/spmj/2015.v133n3/2024-02-20T19:57:28.506000ZVol. 133 No. 3 - 2015WerkzeugEthnicity and cardiovascular mortality in Brazil: a call for papers10.1590/1516-3180.2015.133329042024-02-20T19:57:28.506000Z2020-08-09T06:49:21.481000ZLotufo, Paulo Andrade
<em>Lotufo, Paulo Andrade</em>;
<br/><br/>
Healthcare resource utilization and costs of outpatient follow-up after liver transplantation in a university hospital in São Paulo, Brazil: cost description study10.1590/1516-3180.2013.70000112024-02-20T19:57:28.506000Z2020-08-09T06:49:21.481000ZSoárez, Patricia Coelho deLara, Amanda NazarethSartori, Ana Marli ChristovamAbdala, EdsonHaddad, Luciana Bertocco de PaivaD'Albuquerque, Luiz Augusto CarneiroNovaes, Hillegonda Maria Dutilh
<em>Soárez, Patricia Coelho De</em>;
<em>Lara, Amanda Nazareth</em>;
<em>Sartori, Ana Marli Christovam</em>;
<em>Abdala, Edson</em>;
<em>Haddad, Luciana Bertocco De Paiva</em>;
<em>D'albuquerque, Luiz Augusto Carneiro</em>;
<em>Novaes, Hillegonda Maria Dutilh</em>;
<br/><br/>
CONTEXT AND OBJECTIVE: Data on the costs of outpatient follow-up after liver transplantation are scarce in Brazil. The purpose of the present study was to estimate the direct medical costs of the outpatient follow-up after liver transplantation, from the first outpatient visit after transplantation to five years after transplantation. DESIGN AND SETTING: Cost description study conducted in a university hospital in São Paulo, Brazil. METHODS: Cost data were available for 20 adults who underwent liver transplantation due to acute liver failure (ALF) from 2005 to 2009. The data were retrospectively retrieved from medical records and the hospital accounting information system from December 2010 to January 2011. RESULTS: Mean cost per patient/year was R$ 13,569 (US$ 5,824). The first year of follow-up was the most expensive (R$ 32,546 or US$ 13,968), and medication was the main driver of total costs, accounting for 85% of the total costs over the five-year period and 71.9% of the first-year total costs. In the second year after transplantation, the mean total costs were about half of the amount of the first-year costs (R$ 15,165 or US$ 6,509). Medication was the largest contributor to the costs followed by hospitalization, over the five-year period. In the fourth year, the costs of diagnostic tests exceeded the hospitalization costs. CONCLUSION: This analysis provides significant insight into the costs of outpatient follow-up after liver transplantation due to ALF and the participation of each cost component in the Brazilian setting.The influence of depressive symptoms and substance use on adherence to antiretroviral therapy. A cross-sectional prevalence study10.1590/1516-3180.2013.74500102024-02-20T19:57:28.506000Z2020-08-09T06:49:21.481000ZTufano, Claudia SiqueiraAmaral, Ricardo Abrantes doCardoso, Luciana Roberta DonolaMalbergier, André
<em>Tufano, Claudia Siqueira</em>;
<em>Amaral, Ricardo Abrantes Do</em>;
<em>Cardoso, Luciana Roberta Donola</em>;
<em>Malbergier, André</em>;
<br/><br/>
CONTEXT AND OBJECTIVE: Adherence to antiretroviral treatment (ART) is not a stable condition, but is dynamic, like mental conditions. The aim of this study was to examine whether non-adherence to ART is related to demographic and immunological variables, substance use and presence of depressive symptoms. DESIGN AND SETTING: This was a cross-sectional prevalence study carried out at a public AIDS treatment center in the city of São Paulo, Brazil, between July 2006 and January 2007. METHODS: 438 patients on regular ART schedules with recent laboratory tests answered a demographic questionnaire, questions about substance use, the Hamilton Depression Rating Scale (HDRS) and the Simplified Medication Adherence Questionnaire (SMAQ). RESULTS: The prevalence of non-adherence over the past three months (a pattern of treatment interruption) was 46.3%, and 27.2% also reported this in the past week (a pattern of missed doses). ART interruption was significantly related to older age, lower CD4+ cell count and homosexual/bisexual transmission. The pattern of missed doses was significantly related to younger age, higher HDRS scores and higher viral load of RNA HIV. CONCLUSION: ART interruption may reflect recall errors and changes to the Brazilian demographic characteristics of HIV infection. The missed doses may reflect lifestyle characteristics of younger individuals. Attendance for HIV-positive individuals, particularly younger patients, should involve interventions and counseling in relation to the presence of depressive symptoms.Cold weather is a predisposing factor for testicular torsion in a tropical country. A retrospective study10.1590/1516-3180.2013.76000072024-02-20T19:57:28.506000Z2020-08-09T06:49:21.481000ZGomes, Daniel de OliveiraVidal, Rafael RochaFoeppel, Bruno FigueiredoFaria, Danilo FiorindoSaito, Minori
<em>Gomes, Daniel De Oliveira</em>;
<em>Vidal, Rafael Rocha</em>;
<em>Foeppel, Bruno Figueiredo</em>;
<em>Faria, Danilo Fiorindo</em>;
<em>Saito, Minori</em>;
<br/><br/>
CONTEXT AND OBJECTIVE: Testicular torsion is a medical and urological emergency because it can lead to loss of the organ. The theory of seasonal testicular torsion occurrence is based on studies from institutions located in cold and temperate regions. The objective here was to determine whether cold weather is associated with higher incidence of testicular torsion in a tropical country, such as Brazil. DESIGN AND SETTING: Retrospective study, conducted in a tertiary and teaching hospital. METHODS: Patients with acute testicular torsion confirmed by surgery between April 2006 and March 2011 were studied. Information on weather conditions at the time of symptom onset was collected. RESULTS: A total of 64 testicular torsion cases were identified. The months with the highest incidences of testicular torsion were June (16%), July (19%) and August (11%), which had the lowest mean temperatures, of 17.6 °C, 16.4 °C and 18.2 °C, respectively. Eleven percent of cases occurred during spring (October to December), 16% occurred in summer (January to March), 34% occurred in fall (April to June) and 39% occurred in winter (July to September). There was a significant association between the incidence of testicular torsion and the season (fall and winter), P < 0.001. CONCLUSIONS: Testicular torsion follows a seasonal association even in a tropical country, and is more frequent in the colder months of the year, namely fall and winter, when almost three-quarters of the cases occurred. These observations add further evidence that cold weather has an etiologic role in testicular torsion occurrence.Clinical and cytogenetic features of a Brazilian sample of patients with phenotype of oculo-auriculo-vertebral spectrum: a cross-sectional study10.1590/1516-3180.2013.77622042024-02-20T19:57:28.506000Z2020-08-09T06:49:21.481000ZSilva, Alessandra Pawelec daRosa, Rafael Fabiano MachadoTrevisan, PatríciaDorneles, Juliana CavalheiroMesquita, Camila SaporitiMattos, Vinicius Freitas dePaskulin, Giorgio AdrianoZen, Paulo Ricardo Gazzola
<em>Silva, Alessandra Pawelec Da</em>;
<em>Rosa, Rafael Fabiano Machado</em>;
<em>Trevisan, Patrícia</em>;
<em>Dorneles, Juliana Cavalheiro</em>;
<em>Mesquita, Camila Saporiti</em>;
<em>Mattos, Vinicius Freitas De</em>;
<em>Paskulin, Giorgio Adriano</em>;
<em>Zen, Paulo Ricardo Gazzola</em>;
<br/><br/>
CONTEXT AND OBJECTIVE: Oculo-auriculo-vertebral spectrum (OAVS) is considered to be a defect of embryogenesis involving structures originating from the first branchial arches. Our objective was to describe the clinical and cytogenetic findings from a sample of patients with the phenotype of OAVS. DESIGN AND SETTING: Cross-sectional study in a referral hospital in southern Brazil. METHODS: The sample consisted of 23 patients who presented clinical findings in at least two of these four areas: orocraniofacial, ocular, auricular and vertebral. The patients underwent a clinical protocol and cytogenetic evaluation through high-resolution karyotyping, fluorescence in situ hybridization for 5p and 22q11 microdeletions and investigation of chromosomal instability for Fanconi anemia. RESULTS: Cytogenetic abnormalities were observed in three cases (13%) and consisted of: 47,XX,+mar; mos 47,XX,+mar/46,XX; and 46,XX,t(6;10)(q13; q24). We observed cases of OAVS with histories of gestational exposition to fluoxetine, retinoic acid and crack. One of our patients was a discordant monozygotic twin who had shown asymmetrical growth restriction during pregnancy. Our patients with OAVS were characterized by a broad clinical spectrum and some presented atypical findings such as lower-limb reduction defect and a tumor in the right arm, suggestive of hemangioma/lymphangioma. CONCLUSIONS: We found a wide range of clinical characteristics among the patients with OAVS. Different chromosomal abnormalities and gestational expositions were also observed. Thus, our findings highlight the heterogeneity of the etiology of OAVS and the importance of these factors in the clinical and cytogenetic evaluation of these patients.Feasibility of transitioning from APACHE II to SAPS III as prognostic model in a Brazilian general intensive care unit. A retrospective study10.1590/1516-3180.2013.81200142024-02-20T19:57:28.506000Z2020-08-09T06:49:21.481000ZSerpa Neto, AryAssunção, Murillo Santucci Cesar dePardini, AndréiaSilva, Eliézer
<em>Serpa Neto, Ary</em>;
<em>Assunção, Murillo Santucci Cesar De</em>;
<em>Pardini, Andréia</em>;
<em>Silva, Eliézer</em>;
<br/><br/>
CONTEXT AND OBJECTIVE: Prognostic models reflect the population characteristics of the countries from which they originate. Predictive models should be customized to fit the general population where they will be used. The aim here was to perform external validation on two predictive models and compare their performance in a mixed population of critically ill patients in Brazil. DESIGN AND SETTING: Retrospective study in a Brazilian general intensive care unit (ICU). METHODS: This was a retrospective review of all patients admitted to a 41-bed mixed ICU from August 2011 to September 2012. Calibration (assessed using the Hosmer-Lemeshow goodness-of-fit test) and discrimination (assessed using area under the curve) of APACHE II and SAPS III were compared. The standardized mortality ratio (SMR) was calculated by dividing the number of observed deaths by the number of expected deaths. RESULTS: A total of 3,333 ICU patients were enrolled. The Hosmer-Lemeshow goodness-of-fit test showed good calibration for all models in relation to hospital mortality. For in-hospital mortality there was a worse fit for APACHE II in clinical patients. Discrimination was better for SAPS III for in-ICU and in-hospital mortality (P = 0.042). The SMRs for the whole population were 0.27 (confidence interval [CI]: 0.23 - 0.33) for APACHE II and 0.28 (CI: 0.22 - 0.36) for SAPS III. CONCLUSIONS: In this group of critically ill patients, SAPS III was a better prognostic score, with higher discrimination and calibration power.Overview of systematic reviews - a new type of study. Part II10.1590/1516-3180.2013.81500152024-02-20T19:57:28.506000Z2020-08-09T06:49:21.481000ZSilva, ValterGrande, Antonio JoseCarvalho, Alan Pedrosa Viegas deMartimbianco, Ana Luiza CabreraRiera, Rachel
<em>Silva, Valter</em>;
<em>Grande, Antonio Jose</em>;
<em>Carvalho, Alan Pedrosa Viegas De</em>;
<em>Martimbianco, Ana Luiza Cabrera</em>;
<em>Riera, Rachel</em>;
<br/><br/>
CONTEXT AND OBJECTIVE: Overviews of Systematic Reviews (OoRs) are a new type of study in which multiple evidence from systematic reviews (SRs) is compiled into an accessible and useful document. The aim here was to describe the state of the art and critically assess Cochrane OoRs that have been published. DESIGN AND SETTING: Descriptive study conducted at a research center. METHODS: The OoRs identified through the filter developed in Part I of this study were evaluated in five domains: methodological quality; quality of evidence; implications for practice; general profile of OoRs; and length of work. RESULTS: All 13 OoRs included had high methodological quality. Some OoRs did not present sufficient data to judge the quality of evidence; using sensitivity analysis, the quality of evidence of the OoRs increased. Regarding implications for practice, 64% of the interventions were judged as beneficial or harmful, while 36% of them showed insufficient evidence for judgment. It is expected (with 95% confidence interval) that one OoR will include 9,462 to 64,469 patients, 9 to 29 systematic reviews and 80 to 344 primary studies, and assess 6 to 21 interventions; and that 50 to 92% of OoRs will produce meta-analysis. The OoRs generated 2 to 26 meta-analyses over a period of 18 to 31 months. CONCLUSION: The OoRs presented high methodological quality; the quality of evidence tended to be moderate/high; most interventions were judged to be beneficial/harmful; the mean length of work was 24 months. The OoR profile adds power to decision-making.Direct and indirect cost of attempted suicide in a general hospital: cost-of-illness study10.1590/1516-3180.2014.84918082024-02-20T19:57:28.506000Z2020-08-09T06:49:21.481000ZSgobin, Sara Maria TeixeiraTraballi, Ana Luisa MarquesBotega, Neury JoséCoelho, Otávio Rizi
<em>Sgobin, Sara Maria Teixeira</em>;
<em>Traballi, Ana Luisa Marques</em>;
<em>Botega, Neury José</em>;
<em>Coelho, Otávio Rizi</em>;
<br/><br/>
CONTEXT AND OBJECTIVE: Knowledge of socioeconomic impact of attempted suicide may sensitize managers regarding prevention strategies. There are no published data on this in Brazil. The aim here was to describe the direct and indirect costs of care of hospitalized cases of attempted suicide and compare these with the costs of acute coronary syndrome cases. DESIGN AND SETTING: Cost-of-illness study at a public university hospital in Brazil. METHOD: The costs of care of 17 patients hospitalized due to attempted suicide were compared with those of 17 acute coronary syndrome cases at the same hospital, over the same period. The direct costs were the summation of the hospital and out-of-hospital costs resulting from the event, determined from the medical records. The indirect costs were estimated through the human capital lost. The Mann-Whitney test and analysis of covariance (ANCOVA) with transformation adjusted for age were used for comparisons. RESULTS: The average costs per episode of attempted suicide were: direct cost, US$ 6168.65; indirect cost, US$ 688.08; and total cost, US$ 7163.75. Comparative analysis showed a difference between the indirect costs to family members, with significantly higher costs in the attempted suicide group (P = 0.0022). CONCLUSION: The cost of care relating to attempted suicide is high and the indirect cost to family members reinforces the idea that suicidal behavior not only affects the individual but also his social environment.Comparison of maternal and fetal outcomes among patients undergoing cesarean section under general and spinal anesthesia: a randomized clinical trial10.1590/1516-3180.2014.89010122024-02-20T19:57:28.506000Z2020-08-09T06:49:21.481000ZSaygı, Anıl İçelÖzdamar, ÖzkanGün, İsmetEmirkadı, HakanMüngen, ErcümentAkpak, Yaşam Kemal
<em>Saygı, Anıl İçel</em>;
<em>Özdamar, Özkan</em>;
<em>Gün, İsmet</em>;
<em>Emirkadı, Hakan</em>;
<em>Müngen, Ercüment</em>;
<em>Akpak, Yaşam Kemal</em>;
<br/><br/>
CONTEXT AND OBJECTIVE: As the rates of cesarean births have increased, the type of cesarean anesthesia has gained importance. Here, we aimed to compare the effects of general and spinal anesthesia on maternal and fetal outcomes in term singleton cases undergoing elective cesarean section. DESIGN AND SETTING: Prospective randomized controlled clinical trial in a tertiary-level public hospital. METHODS: Our study was conducted on 100 patients who underwent cesarean section due to elective indications. The patients were randomly divided into general anesthesia (n = 50) and spinal anesthesia (n = 50) groups. The maternal pre and postoperative hematological results, intra and postoperative hemodynamic parameters and perinatal results were compared between the groups. RESULTS: Mean bowel sounds (P = 0.036) and gas discharge time (P = 0.049) were significantly greater and 24th hour hemoglobin difference values (P = 0.001) were higher in the general anesthesia group. The mean hematocrit and hemoglobin values at the 24th hour (P = 0.004 and P < 0.001, respectively), urine volume at the first postoperative hour (P < 0.001) and median Apgar score at the first minute (P < 0.0005) were significantly higher, and the time that elapsed until the first requirement for analgesia was significantly longer (P = 0.042), in the spinal anesthesia group. CONCLUSION: In elective cases, spinal anesthesia is superior to general anesthesia in terms of postoperative comfort. In pregnancies with a risk of fetal distress, it would be appropriate to prefer spinal anesthesia by taking the first minute Apgar score into account.Tobacco and alcohol use, sexual behavior and common mental disorders among military students at the Police Academy, São Paulo, Brazil. A cross-sectional study10.1590/1516-3180.2014.91027112024-02-20T19:57:28.506000Z2020-08-09T06:49:21.481000ZPerez, Arlene de MariaBenseñor, Isabela Martins
<em>Perez, Arlene De Maria</em>;
<em>Benseñor, Isabela Martins</em>;
<br/><br/>
CONTEXT AND OBJECTIVE: The lifestyle of military personnel has been little studied in Brazil. This study evaluated the frequencies of tobacco and alcohol use, sexual behavior and mental health among military students. DESIGN AND SETTING: Cross-sectional study at the Police Academy, in São Paulo. METHODS: Students answered a questionnaire about tobacco use, alcohol consumption, sexual behavior and common mental disorders (CMDs). To analyze associations among the frequencies of smoking and alcohol use, sexually transmitted diseases (STDs) and CMDs during the undergraduate years, we built a multinomial logistic regression model adjusted for age and sex. RESULTS: All 473 students were invited to participate and 430 (90.9%) agreed (10.5% were women). Most were white (76.6%), aged < 30 years, from the upper middle class (78.1%). The frequency of smoking was 6.5%, alcohol consumption 69.3%, STDs 14% and CMDs 15.6%. The use of condoms was low. Fourth-year students presented a lower odds ratio (OR) for STDs than the first-year students: 0.44 (95% confidence interval: 0.22-0.90). Third-year students presented a lower OR for CMDs than the first-year students. CONCLUSION: The frequencies of smoking and CMDs were low, while the frequency of alcohol consumption was similar to that of the Brazilian population. The use of condoms was low, in comparison with previous studies with similar samples. The results suggest that there was a certain degree of protection against CMDs and STDs during the undergraduate years.Incidence of chronic obstructive pulmonary disease based on three spirometric diagnostic criteria in Sao Paulo, Brazil: a nine-year follow-up since the PLATINO prevalence study10.1590/1516-3180.2015.96209022024-02-20T19:57:28.506000Z2020-08-09T06:49:21.481000ZMoreira, Graciane LaenderGazzotti, Mariana RodriguesManzano, Beatriz MartinsNascimento, OliverPerez-Padilla, RogelioMenezes, Ana Maria BaptistaJardim, José Roberto
<em>Moreira, Graciane Laender</em>;
<em>Gazzotti, Mariana Rodrigues</em>;
<em>Manzano, Beatriz Martins</em>;
<em>Nascimento, Oliver</em>;
<em>Perez-Padilla, Rogelio</em>;
<em>Menezes, Ana Maria Baptista</em>;
<em>Jardim, José Roberto</em>;
<br/><br/>
CONTEXT AND OBJECTIVE: Chronic obstructive pulmonary disease (COPD) is a respiratory disease of high prevalence and socioeconomic impact worldwide. It affects approximately 16% of the population of São Paulo. The incidence of COPD is still unknown in Brazil. The aim of this study was to estimate new cases of COPD in a population-based sample in São Paulo, Brazil, using three different spirometric diagnostic criteria, and to assess the concordance between these criteria. DESIGN AND SETTING: Prospective cohort study, in the city of São Paulo, Brazil. METHODS: A questionnaire was applied and anthropometry and pre and post-bronchodilator spirometry were performed on the same subjects as in the initial PLATINO study (2003) in São Paulo. Data from this follow-up study were added to the original database of the initial phase. Incident COPD cases refer to subjects who developed the disease in accordance with each spirometric criterion during the nine-year follow-up period. The Statistical Package for the Social Sciences, version 17.0 (SPSS Inc., Chicago, IL, USA) was used in the analysis and the significance level was set at P < 0.05. RESULTS: 613 subjects participated in the follow-up. New COPD cases ranged in frequency from 1.4% to 4.0%, depending on the diagnostic criterion used. The concordance between the criteria ranged from 35% to 60%. CONCLUSION: The incidence of COPD after a nine-year follow-up was high, but varied according to the spirometric criterion used. The agreement between the criteria for identifying new cases of the disease ranged from 35% to 60%.The Escitalopram versus Electric Current Therapy for Treating Depression Clinical Study (ELECT-TDCS): rationale and study design of a non-inferiority, triple-arm, placebo-controlled clinical trial10.1590/1516-3180.2014.003517122024-02-20T19:57:28.506000Z2020-08-09T06:49:21.481000ZBrunoni, André RussowskySampaio-Junior, BernardoMoffa, Adriano HenriqueBorrione, LucasNogueira, Barbara SchwairAparício, Luana Vanessa MarottiVeronezi, BeatrizMoreno, MarinaFernandes, Raquel AlbanoTavares, DiegoBueno, Priscila Vilela SilveiraSeibt, OleBikson, MaromFraguas, RenerioBenseñor, Isabela Martins
<em>Brunoni, André Russowsky</em>;
<em>Sampaio-Junior, Bernardo</em>;
<em>Moffa, Adriano Henrique</em>;
<em>Borrione, Lucas</em>;
<em>Nogueira, Barbara Schwair</em>;
<em>Aparício, Luana Vanessa Marotti</em>;
<em>Veronezi, Beatriz</em>;
<em>Moreno, Marina</em>;
<em>Fernandes, Raquel Albano</em>;
<em>Tavares, Diego</em>;
<em>Bueno, Priscila Vilela Silveira</em>;
<em>Seibt, Ole</em>;
<em>Bikson, Marom</em>;
<em>Fraguas, Renerio</em>;
<em>Benseñor, Isabela Martins</em>;
<br/><br/>
CONTEXT AND OBJECTIVE: Major depressive disorder (MDD) is a common psychiatric condition, mostly treated with antidepressant drugs, which are limited due to refractoriness and adverse effects. We describe the study rationale and design of ELECT-TDCS (Escitalopram versus Electric Current Therapy for Treating Depression Clinical Study), which is investigating a non-pharmacological treatment known as transcranial direct current stimulation (tDCS). DESIGN AND SETTING: Phase-III, randomized, non-inferiority, triple-arm, placebo-controlled study, ongoing in São Paulo, Brazil. METHODS: ELECT-TDCS compares the efficacy of active tDCS/placebo pill, sham tDCS/escitalopram 20 mg/day and sham tDCS/placebo pill, for ten weeks, randomizing 240 patients in a 3:3:2 ratio, respectively. Our primary aim is to show that tDCS is not inferior to escitalopram with a non-inferiority margin of at least 50% of the escitalopram effect, in relation to placebo. As secondary aims, we investigate several biomarkers such as genetic polymorphisms, neurotrophin serum markers, motor cortical excitability, heart rate variability and neuroimaging. RESULTS: Proving that tDCS is similarly effective to antidepressants would have a tremendous impact on clinical psychiatry, since tDCS is virtually devoid of adverse effects. Its ease of use, portability and low price are further compelling characteristics for its use in primary and secondary healthcare. Multimodal investigation of biomarkers will also contribute towards understanding the antidepressant mechanisms of action of tDCS. CONCLUSION: Our results have the potential to introduce a novel technique to the therapeutic arsenal of treatments for depression.Construction of a competence-based curriculum for internship in obstetrics and gynecology within the medical course at the Federal University of Ceará (Sobral campus)10.1590/1516-3180.2014.08048722024-02-20T19:57:28.506000Z2020-08-09T06:49:21.481000ZLinhares, José JuvenalDutra, Bárbara de Araújo LimaPonte, Maycon Fellipe daTofoli, Luis Fernando Farah deTávora, Priscila CamposMacedo, Filipe Sancho deArruda, Guarany Mont'Alverne de
<em>Linhares, José Juvenal</em>;
<em>Dutra, Bárbara De Araújo Lima</em>;
<em>Ponte, Maycon Fellipe Da</em>;
<em>Tofoli, Luis Fernando Farah De</em>;
<em>Távora, Priscila Campos</em>;
<em>Macedo, Filipe Sancho De</em>;
<em>Arruda, Guarany Mont'alverne De</em>;
<br/><br/>
CONTEXT AND OBJECTIVE: This research project arose from a proposal made to the teachers by the students of a medical course at a federal university in Brazil, from their personal experiences regarding the skills and competencies that should be developed during the obstetrics and gynecology (OBG) stage of the internship. The objective here was to develop the matrix of skills necessary for training good general physicians in the medical course. DESIGN AND SETTING: Exploratory qualitative study conducted in a federal university in Brazil. METHODS: The basis for developing these competencies among OBG interns was "The Competency Matrix for Medical Internship" developed by Bollela and Machado. The instrument was presented to, analyzed by and modified by a set of OBG specialists, at two sessions. RESULTS: The specific competencies expected from students over the internship in OBG were framed within overall topics that had previously been determined and listed: healthcare, decision-making, communication and interpersonal relationships, management and organization of the Brazilian National Health System (Sistema Único de Saúde, SUS) and professionalism. CONCLUSIONS: A competency matrix that standardizes the minimum requirements that interns should be capable of putting into practice after concluding the OBG stage is a valuable tool for ensuring student performance and a fair and rigorous assessment for them, thereby seeking to train good general physicians who meet the community's needs.Azacitidine and lenalidomide as an alternative treatment for refractory acute myeloid leukemia: a case report10.1590/1516-3180.2012.67900062024-02-20T19:57:28.506000Z2020-08-09T06:49:21.481000ZTodaro, JulianaBollmann, Patrícia WeinschenkerRother, Edna TerezinhaGiglio, Auro del
<em>Todaro, Juliana</em>;
<em>Bollmann, Patrícia Weinschenker</em>;
<em>Rother, Edna Terezinha</em>;
<em>Giglio, Auro Del</em>;
<br/><br/>
CONTEXT: Refractory acute myeloid leukemia (AML) is a difficult disease to control with second or third-line chemotherapy regimens. In this report, we describe using azacitidine in combination with lenalidomide as salvage therapy. CASE REPORT: 52-year-old female was diagnosed with refractory AML and high-risk cytogenetics: complex monosomal karyotype consisting of t (3, 3) in association with monosomy 7 and del 5q. Morphological remission associated with maintenance of the cytogenetic abnormality of chromosome 3 and disappearance of the abnormalities relating to chromosomes 5 and 7 was achieved after three cycles of combination therapy with azacitidine and lenalidomide. CONCLUSION: Azacitidine plus lenalidomide can be a therapeutic option for patients with refractory AML, as illustrated in this case.Aortic dissection during antiangiogenic therapy with sunitinib. A case report10.1590/1516-3180.2013.73800022024-02-20T19:57:28.506000Z2020-08-09T06:49:21.481000ZFormiga, Maria Nirvana da CruzFanelli, Marcello Ferretti
<em>Formiga, Maria Nirvana Da Cruz</em>;
<em>Fanelli, Marcello Ferretti</em>;
<br/><br/>
CONTEXT: Sunitinib is an antiangiogenic drug that has been approved for treating metastatic renal cancer. Its action as a tyrosine kinase inhibitor of vascular endothelial growth factor receptors (VEGFRs) and other angiogenesis receptors may lead to adverse effects such as hypertension and heart failure. However, reports in the literature on an association between sunitinib therapy and acute aortic dissection are rare. CASE REPORT: We report the case of a 68-year-old man with metastatic renal carcinoma who developed acute aortic dissection during sunitinib therapy. He had no history of hypertension or any other risk factor for aortic dissection. After aortic dissection had been diagnosed, sunitinib was withdrawn and an aortic endoprosthesis was placed. Afterwards, the patient was treated clinically with antihypertensive drugs and new therapy for renal cancer consisting of temsirolimus, an inhibitor of the mammalian target of rapamycin (mTOR) pathway. CONCLUSION: Hypertension is a common event when antiangiogenic drugs are used in oncology. However, knowledge of other severe cardiovascular events that may occur in these patients, such as acute aortic dissection, is important. Adequate control over arterial pressure and frequent monitoring of patients during the first days of antiangiogenic therapy is essential for early diagnosis of possible adverse events.Blood pressure control for diabetic retinopathy10.1590/1516-3180.20151333T12024-02-20T19:57:28.506000Z2020-08-09T06:49:21.481000ZDo, Diana V.Wang, XueVedula, Satyanarayana S.Marrone, MichaelSleilati, GinaHawkins, Barbara S.Frank, Robert N.
<em>Do, Diana V.</em>;
<em>Wang, Xue</em>;
<em>Vedula, Satyanarayana S.</em>;
<em>Marrone, Michael</em>;
<em>Sleilati, Gina</em>;
<em>Hawkins, Barbara S.</em>;
<em>Frank, Robert N.</em>;
<br/><br/>
BACKGROUND: Diabetic retinopathy is a common complication of diabetes and a leading cause of visual impairment and blindness. Research has established the importance of blood glucose control to prevent development and progression of the ocular complications of diabetes. Simultaneous blood pressure control has been advocated for the same purpose, but findings reported from individual studies have supported varying conclusions regarding the ocular benefit of interventions on blood pressure. OBJECTIVES: The primary aim of this review was to summarize the existing evidence regarding the effect of interventions to control or reduce blood pressure levels among diabetics on incidence and progression of diabetic retinopathy, preservation of visual acuity, adverse events, quality of life, and costs. A secondary aim was to compare classes of anti-hypertensive medications with respect to the same outcomes. METHODS: Search methods: We searched a number of electronic databases including CENTRAL as well as ongoing trial registries. We last searched the electronic databases on 25 April 2014. We also reviewed reference lists of review articles and trial reports selected for inclusion. In addition, we contacted investigators of trials with potentially pertinent data. Selection criteria: We included in this review randomized controlled trials (RCTs) in which either type 1 or type 2 diabetic participants, with or without hypertension, were assigned randomly to intense versus less intense blood pressure control, to blood pressure control versus usual care or no intervention on blood pressure, or to different classes of anti-hypertensive agents versus placebo. Data collection and analysis: Pairs of review authors independently reviewed titles and abstracts from electronic and manual searches and the full text of any document that appeared to be relevant. We assessed included trials independently for risk of bias with respect to outcomes reported in this review. We extracted data regarding trial characteristics, incidence and progression of retinopathy, visual acuity, quality of life, and cost-effectiveness at annual intervals after study entry whenever provided in published reports and other documents available from included trials. MAIN RESULTS: We included 15 RCTs, conducted primarily in North America and Europe, that had enrolled 4157 type 1 and 9512 type 2 diabetic participants, ranging from 16 to 2130 participants in individual trials. In 10 of the 15 RCTs, one group of participants was assigned to one or more anti-hypertensive agents and the control group received placebo. In three trials, intense blood pressure control was compared to less intense blood pressure control. In the remaining two trials, blood pressure control was compared with usual care. Five of the 15 trials enrolled type 1 diabetics, and 10 trials enrolled type 2 diabetics. Six trials were sponsored entirely by pharmaceutical companies, seven trials received partial support from pharmaceutical companies, and two studies received support from government-sponsored grants and institutional support. Study designs, populations, interventions, and lengths of follow-up (range one to nine years) varied among the included trials. Overall, the quality of the evidence for individual outcomes was low to moderate. For the primary outcomes, incidence and progression of retinopathy, the quality of evidence was downgraded due to inconsistency and imprecision of estimates from individual studies and differing characteristics of participants. For primary outcomes among type 1 diabetics, one of the five trials reported incidence of retinopathy and one trial reported progression of retinopathy after 4 to 5 years of treatment and follow-up; four of the five trials reported a combined outcome of incidence and progression over the same time interval. Among type 2 diabetics, 5 of the 10 trials reported incidence of diabetic retinopathy and 3 trials reported progression of retinopathy; one of the 10 trials reported a combined outcome of incidence and progression during a 4- to 5-year follow-up period. One trial in which type 2 diabetics participated had reported no primary (or secondary) outcome targeted for this review. The evidence from these trials supported a benefit of more intensive blood pressure control intervention with respect to 4- to 5-year incidence of diabetic retinopathy (estimated risk ratio (RR) 0.80; 95% confidence interval (CI) 0.71 to 0.92) and the combined outcome of incidence and progression (estimated RR 0.78; 95% CI 0.63 to 0.97). The available evidence provided less support for a benefit with respect to 4- to 5-year progression of diabetic retinopathy (point estimate was closer to 1 than point estimates for incidence and combined incidence and progression, and the CI overlapped 1; estimated RR 0.88; 95% CI 0.73 to 1.05). The available evidence regarding progression to proliferative diabetic retinopathy or clinically significant macular edema or moderate to severe loss of best-corrected visual acuity did not support a benefit of intervention on blood pressure: estimated RRs and 95% CIs 0.95 (0.83 to 1.09) and 1.06 (0.85 to 1.33), respectively, after 4 to 5 years of follow-up. Findings within subgroups of trial participants (type 1 and type 2 diabetics; participants with normal blood pressure levels at baseline and those with elevated levels) were similar to overall findings. The adverse event reported most often (7 of 15 trials) was death, yielding an estimated RR 0.86 (95% CI 0.64 to 1.14). Hypotension was reported from three trials; the estimated RR was 2.08 (95% CI 1.68 to 2.57). Other adverse ocular events were reported from single trials. AUTHORS' CONCLUSIONS: Hypertension is a well-known risk factor for several chronic conditions in which lowering blood pressure has proven to be beneficial. The available evidence supports a beneficial effect of intervention to reduce blood pressure with respect to preventing diabetic retinopathy for up to 4 to 5 years. However, the lack of evidence to support such intervention to slow progression of diabetic retinopathy or to prevent other outcomes considered in this review, along with the relatively modest support for the beneficial effect on incidence, weakens the conclusion regarding an overall benefit of intervening on blood pressure solely to prevent diabetic retinopathy.Reduced dietary salt for the prevention of cardiovascular disease10.1590/1516-3180.20151333T22024-02-20T19:57:28.506000Z2020-08-09T06:49:21.481000ZAdler, Alma J.Taylor, FionaMartin, NicoleGottlieb, SheldonTaylor, Rod S.Ebrahim, Shah
<em>Adler, Alma J.</em>;
<em>Taylor, Fiona</em>;
<em>Martin, Nicole</em>;
<em>Gottlieb, Sheldon</em>;
<em>Taylor, Rod S.</em>;
<em>Ebrahim, Shah</em>;
<br/><br/>
BACKGROUND: This is an update of a Cochrane review that was first published in 2011 of the effects of reducing dietary salt intake, through advice to reduce salt intake or low-sodium salt substitution, on mortality and cardiovascular events. OBJECTIVES: 1. To assess the long-term effects of advice and salt substitution, aimed at reducing dietary salt, on mortality and cardiovascular morbidity. 2. To investigate whether a reduction in blood pressure is an explanatory factor in the effect of such dietary interventions on mortality and cardiovascular outcomes. METHODS: Search methods: We updated the searches of CENTRAL (2013, Issue 4), MEDLINE (OVID, 1946 to April week 3 2013), EMBASE (OVID, 1947 to 30 April 2013) and CINAHL (EBSCO, inception to 1 April 2013) and last ran these on 1 May 2013. We also checked the references of included studies and reviews. We applied no language restrictions. Selection criteria: Trials fulfilled the following criteria: (1) randomised, with follow-up of at least six months, (2) the intervention was reduced dietary salt (through advice to reduce salt intake or low-sodium salt substitution), (3) participants were adults and (4) mortality or cardiovascular morbidity data were available. Two review authors independently assessed whether studies met these criteria. Data collection and analysis: A single author extracted data and assessed study validity, and a second author checked this. We contacted trial authors where possible to obtain missing information. We extracted events and calculated risk ratios (RRs) and 95% confidence intervals (CIs). MAIN RESULTS: Eight studies met the inclusion criteria: three in normotensives (n = 3518) and five in hypertensives or mixed populations of normo- and hypertensives (n = 3766). End of trial follow-up ranged from six to 36 months and the longest observational follow-up (after trial end) was 12.7 years. The risk ratios (RR) for all-cause mortality in normotensives were imprecise and showed no evidence of reduction (end of trial RR 0.67, 95% confidence interval (CI) 0.40 to 1.12, 60 deaths; longest follow-up RR 0.90, 95% CI 0.58 to 1.40, 79 deaths n = 3518) or in hypertensives (end of trial RR 1.00, 95% CI 0.86 to 1.15, 565 deaths; longest follow-up RR 0.99, 95% CI 0.87 to 1.14, 674 deaths n = 3085). There was weak evidence of benefit for cardiovascular mortality (hypertensives: end of trial RR 0.67, 95% CI 0.45 to 1.01, 106 events n = 2656) and for cardiovascular events (hypertensives: end of trial RR 0.76, 95% CI 0.57 to 1.01, 194 events, four studies, n = 3397; normotensives: at longest follow-up RR 0.71, 95% CI 0.42 to 1.20, 200 events; hypertensives: RR 0.77, 95% CI 0.57 to 1.02, 192 events; pooled analysis of six trials RR 0.77, 95% CI 0.63 to 0.95, n = 5912). These findings were driven by one trial among retirement home residents that reduced salt intake in the kitchens of the homes, thereby not requiring individual behaviour change. Advice to reduce salt showed small reductions in systolic blood pressure (mean difference (MD) -1.15 mmHg, 95% CI -2.32 to 0.02 n = 2079) and diastolic blood pressure (MD -0.80 mmHg, 95% CI -1.37 to -0.23 n = 2079) in normotensives and greater reductions in systolic blood pressure in hypertensives (MD -4.14 mmHg, 95% CI -5.84 to -2.43 n = 675), but no difference in diastolic blood pressure (MD -3.74 mmHg, 95% CI -8.41 to 0.93 n = 675). Overall many of the trials failed to report sufficient detail to assess their potential risk of bias. Health-related quality of life was assessed in one trial in normotensives, which reported significant improvements in well-being but no data were presented. AUTHORS' CONCLUSIONS: Despite collating more event data than previous systematic reviews of randomised controlled trials, there is insufficient power to confirm clinically important effects of dietary advice and salt substitution on cardiovascular mortality in normotensive or hypertensive populations. Our estimates of the clinical benefits from advice to reduce dietary salt are imprecise, but are larger than would be predicted from the small blood pressure reductions achieved. Further well-powered studies would be needed to obtain more precise estimates. Our findings do not support individual dietary advice as a means of restricting salt intake. It is possible that alternative strategies that do not require individual behaviour change may be effective and merit further trials.